Form

Basic Information
NOTE: Please be as detailed as possible with your answers. If there is something not applicable to your child, please write N/A.
Parent 1 Name*

First NameLast Name
Parent 2 Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Timezone*
PST/EST/MT/CT
Child's Name*

First NameLast Name
Child's Age*
Medical
Was your child born full-term?*
Full-term is 37 weeks
Gestational age at birth*
Any complications during pregnancy, birth, or postpartum?*
Where is your child with their milestones? Please list any/all they have already reached: rolling, sitting, crawling, standing, cruising, walking. Are there any diagnosed or suspected developmental delays?*
Any NICU time? If yes, how long and why?*
Any known medical conditions?*
Any reflux, CMPA, allergies, or feeding issues?*
Has your pediatrician expressed any concerns about growth or development?*
Reasons for Seeking Support
What are your top 3 sleep concerns? How long have they been an issue? What would be a succesful outcome at the end of us working together?*
Please describe in detail what you have already tried. Did you try them at the same time, or separately?*
What worked, even briefly or partially? *
Feeding
How is your child fed?*

BreastfeedingFormulaCombo-fedExclusive pumpingMy child is 12+ monthsOther
Any feeding aversions or challenges?*
Please describe how often your child nurses/takes a bottle during the day, and how often they feed overnight.*
Are the night feeds full feeds or are they snacking? Does your your child fall back asleep after night feeds? Does he/she wake up really soon after feeding?*
Are you planning on night-weaning or reducing night feeds if appropriate? If you are breastfeeding, have you had a lactation consultant clear you for night weaning? Otherwise, a pediatrician?*
Has your child started solids?*
How many snacks/meals per day? Are you worried if your child is hungry?*
Sleep Environment
Describe where your child sleeps. In the parents room or their own? Do they share a room with a sibling? Are you co-sleeping? Crib, bassinet, toddler bed, or floor mattress?*
Does the sleep environment have black-out curtains? Do you use white noise? *
Does your child use a pacifier? If it falls out does he/she wake-up?*
What is their bedtime and nap-time routine? For example, does he/she have a bath, read books, etc. etc. before sleep?*
Does your child get any screen-time, and if so how much?*
(For toddlers) is your child trying and/or able to leave their room? Do you have a baby-gate or reverse lock in place?
Child's Temperament (6+ months only)
Please describe your child's temperament. Is your child generally calm or high-energy? How quickly do they get used to a new environment or people? Are they easily distracted from tantrums?
Sleep Schedule
Do you follow a schedule? If so, do you use wake-windows or do you go by-the-clock? Please describe their schedule for an average day.*
Please describe their night sleep: What is their typical bedtime and wake-time? How long does it take for them to fall asleep? How do they fall asleep? How many night wakings happen, and how do you handle them?*
How many naps per day? How long? Where are they (crib, car, stroller, contact, etc)? How do they fall asleep for naps? Are their naps consistent / does your child resist naps?*
How do you tell if your child is ready to sleep?*
If your child attends daycare, do they have a nap schedule? If so, what is it? How well does your child sleep there? *
Parent's Well-being & Preferences
Are you experiencing Postpartum Depression / Postpartum Anxiety? *
Who will be helping with the sleep plan? Is everyone on board?*
How do you feel about sleep-training in general? Are there any methods you absolutely do NOT want to use?*
How do you feel about crying? If your child is upset, can you step out of the room for 1 minute? What feels emotionally acceptable to you, and what feels like too much?*
General
(For toddlers) does your child have any night-time fears? Are they afraid of the dark / monsters / ghosts? Do they have nightmares or night terrors?
(For toddlers) is your child potty-trained / are you planning on potty-training soon? Are you using diapers overnight?
Will there be any interruptions in the next 2-3 weeks (vacation, visitors)?
Anything else I should know about?
Should be Empty:

Basic Information

NOTE: Please be as detailed as possible with your answers. If there is something not applicable to your child, please write N/A.

Medical

Reasons for Seeking Support

Feeding

Sleep Environment

Child's Temperament (6+ months only)

Sleep Schedule

Parent's Well-being & Preferences

General